Confusion regarding similar HIV-drug brand names has
resulted in at least 10 prescription errors, according to the
Medication Errors Reporting (MER) program. In a recent issue of
the USP Quality Review, the MER program, which is operated by the
non-profit US Pharmacopeia (USP), said the errors were in reading
and copying orders and in filling prescriptions for HIV
medication. Most common was confusion between Retrovir, the
brand name of zidovudine or AZT, and protease inhibitor
ritonavir; and confusion between the anticonvulsant lamotrigine
and the antiviral lamivudine. In "Errors With Antivirals
Increase Risk to Patients," MER also noted that one patient was
sent to intensive care after his prescription for the protease
inhibitor saquinavir was filled with the antidepressant Sinequan.

To avoid further confusion, the USP recommends ordering drugs by
both brand and generic names; keeping stock of similarly named
drugs in separate areas; avoiding abbreviations; and ascertaining
the knowledge of patients, practitioners, and staff regarding
these drugs.

The CDC National Center for HIV, STD, and TB Prevention makes this information available as a public service only. Providing this information does not constitute endorsement by the CDC. Reproduction of this text is encouraged; however, copies may not be sold, and the CDC National AIDS Clearinghouse should be cited as the source. Copyright 1996, Information, Inc., Bethesda, MD

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